A COPD patient suffered a “horrific” death after mainline oxygen supply was connected to his urinary catheter, causing his abdomen to blow up “like a balloon”.
It should have been a straightforward treat-and-discharge scenario when Stephen Herczeg presented for a urinary tract infection at the Queen Elizabeth Hospital in South Australia’s Woodville.
But instead the 72-year-old died a “horrific” and “traumatic” death after an unknown person connected his oxygen supply tube to his catheter, eventually causing his bladder to rupture and lungs to collapse, SA state coroner Mark Johns said in findings handed down on 10 August.
Mr Herczeg arrived at the hospital emergency department in the early hours of 19 September 2016 and was put on 4 L oxygen via nasal cannula.
Around midday he was assessed by the respiratory team, who noted he was in atrial fibrillation at 150 BPM, had a clear chest X-Ray, had oxygen saturation levels of 87% on room air.
Nurse case notes entered in the hospital’s electronic communication system show the team set an acceptable oxygen saturation rate as between 85% to 92% because Mr Herczeg was a CO2 retainer.
The notes also said Mr Herczeg had 87% oxygen saturation levels on room air and the respiratory team requested for nursing staff not to commence oxygen if possible.
But the team’s request to avoid oxygen was not followed.
At 2.55 pm nurse observations record Mr Herczeg saturating at 96% on 2 litres of oxygen via nasal cannula, the nurse later conceding he did not understand the dangers of administering too much oxygen to a CO2 retainer.
It is unclear whether Mr Herczeg was receiving oxygen during transfer to the ward, based on evidence given by nurses and case notes in the system.
But a nurse did connect his nasal cannulas to mainline oxygen supply when he arrived at ward South 1 at about 3 pm.
For the next two hours, nurse observation of Mr Herczeg was minimal, with staff attending three times at most, which the coroner described as inadequate given the COPD patient was not on continuous pulse and oximetry monitoring.
At 5:05 pm Mr Herczeg was heard yelling in pain.
A nurse found him curled in foetal position and left immediately to page a doctor to enquire if pain relief could be given.